One significant factor in this trend is time. For optimal outcomes, patients with critical injuries need to get medical attention within 60 minutes, according to anecdotal evidence and military research. If this “golden hour” runs out, death becomes much more likely.

“What we know in trauma is that the sooner you get to a surgeon with all the resources and testing capabilities, survival outcomes increase dramatically,” says Andy Gienapp, director of the Wyoming office of Emergency Medical Services. “But in a small community or wilderness parts of America without ambulance service, if you have a bad injury, heart attack or stroke, it’s going to be a while until someone gets to you.”

Up in mountain towns, across swaths of farmland, in barren stretches of desert and deep on country roads, there’s no shortage of barriers to timely treatment for serious injuries. Medical facilities are short on both doctors and vital resources like blood. Emergency response services are underfunded and understaffed. Designated trauma centers are few and far between. Yet experts say that promising new advances in telemedicine and increased emphasis on community-based healthcare can help address some of these gaps in care.

Small-town medicine

Twenty percent of Americans live in rural areas, but fewer than 10 percent of physicians practice there. Many doctors flock to cities, where jobs at top hospitals and competitive practices are professionally and financially rewarding. Yet for other medical professionals, there’s something to be said for the connections a small-town doctor forms with patients. The obligation to furnish high-level care stems both from professional duty and personal investment.

Now primarily a clinical professor of surgery at the University of Kansas School of Medicine, Dr. Tyler Hughes worked in rural America in elective and emergency surgery for more than two decades, after spending the first 12 years of his career at a general surgery practice in Dallas.

“Over the course of 20-plus years, you see generations of people,” says Hughes, who operated on the children of patients he knew as children. While Hughes enjoyed working in a close-knit community, he acknowledges inherent challenges in rural medicine. “Rural surgery is a lot like playing chess, as far as the lack of resources and the distances involved,” he says. “You have to think seven moves ahead, like a chess player.”

Traveling for trauma care

Everywhere in the U.S., survivors of serious accidents like fires, car crashes and shootings are supposed to be treated at regionally designated trauma centers that are staffed and stocked for the situation. Trauma centers are classified as Level I through Level V, with a separate scale for pediatric care and strokes. Level I and II trauma centers are equipped to handle worst-case scenarios. Level V centers can provide life support and stabilization before patients are transferred to higher-tier facilities.

Most states have at least oneLevel I trauma center: Georgia has two; New York has 12.But some states, such as Wyoming and South Dakota, don’t have any. Idaho doesn’t even have a Level II center. Legally, that’s fine — there are no federal requirements for states to have higher-tier trauma centers. But it does mean that patients in need of specialized or life-saving care need to be airlifted across state lines.

“In rural trauma, dying at the scene is more common.”

In cities, 35 percent of emergency departments are level I, II or III trauma centers. In the country, that number drops to 2.4 percent, according to the Agency for Healthcare Research and Quality. Meanwhile, closures of rural hospitals — with and without trauma designations — have accelerated, per an August 2018 report from the University of North Carolina Cecil B. Sheps Center for Health Services Research. Eighty-seven have closed in recent years, and more are on the chopping block.

The small facilities that dominate rural hospital care aren’t an ideal destination for critically injured patients. “To stabilize, a patient needs rapid, confident and aggressive emergency treatment,” Gienapp says. “But if you have a physician who hasn’t put in a chest tube in two or three years, they may not feel confident about doing something like that, when it’s needed to save a life.”

What’s needed, Hughes says, is a “vigilant” emergency management system. “In rural trauma,” he explained, “dying at the scene is more common.”

Emergency services in danger

In rural communities, ambulances aren’t in heavy rotation like they are in cities, so it’s more expensive to send one out. Historically, rural emergency medical services have depended on a mix of private and public funding to cover the cost of operating in large service areas. They also save money by relying on a volunteer workforce.

When the volunteers driving those ambulances get called on, they typically need to leave their day job and drive up to 30 minutes just to pick up the ambulance. From there, they head to the trauma site. In cases of multiple injuries, backup may be called in from much farther away.

“Ambulance services respond to a primary care area of up to 135 miles, so if you’re a person having heart attack, that’s a long wait,” says Gary Wingrove, a longtime rural paramedic now living in Crescent City, Florida. “If you’re traveling 135 miles to get to that trauma victim, the golden hour has already passed before you’ve reached them.”

Wingrove has been on the front lines of rural emergency response for decades. Growing up in small-town Iowa, he began volunteering as an ambulance attendant during his senior year of high school. “I got to leave school to go on ambulance runs,” he says. He later worked as a paramedic in Minnesota, eventually becoming the first paramedic to be president of a state rural health association.

“Rural paramedics need to be among the most competent of the ambulance workforce, because they’re with patients for a longer period of time.”

Paramedic expertise is critical when facing longer distances. Though the term “paramedic” is commonly used to mean any ambulance personnel, there are actually multiple levels of emergency responders, with titles and certification requirements that vary by state. In general, those certified to do basic EMS work can assess patients and furnish life-support assistance, like CPR. Advanced responders can perform more complicated life-saving procedures, like IV insertion. At the top are paramedics, who are trained in a wider array of medical skills, like reading X-rays, administering drugs and performing manual defibrillation.

“A person has to train 120 to 150 hours to get a basic EMS license,” says Roger Wells, a physician assistant at the Howard County Medical Center in Nebraska. Paramedic training is a heavier load. As a volunteer pursuit, paramedic certification is a lot to take on.

“Rural paramedics need to be among the most competent of the ambulance workforce,” Wingrove says, “because they’re with patients for a longer period of time.”

“The requirements are outstripping the ability of local communities,” Wells says. “EMTs are rarely appreciated, within the healthcare system, by communities or by the patients for the time, dedication and effort that is required to complete their duties in mostly volunteer rural system.”

Where treatment is concerned, “it’s seen as not sexy or relevant,” Gienapp says, of emergency services. Firefighters carrying people out of the World Trade Center offers a powerful image, but dialing up 911 for a medical emergency won’t necessarily get you an immediate response. “People don’t think about it,” he says. “They just call 911 and are surprised when the ambulance takes 30 or 40 minutes to arrive.”

In larger communities, an ambulance can choose between a hospital specializing in heart or trauma-related issues. There’s often no such choice in smaller towns, where first responders must quickly decide between immediate air transport and driving to a local regional hospital or a facility where the patient can be “packaged” and airlifted to a higher-level center.

In microcommunities that max out at populations of 100 or 200, it may not make financial sense to run an emergency service. But Gienapp points out that even small towns can plan for emergencies, such as by having an automatic defibrillator, or AED, to jumpstart hearts, providing CPR training for community members and pairing up with larger neighboring communities to provide emergency services.

A better-coordinated state and federal infrastructure for emergency response is needed, Gienapp says, noting that few federal dollars go to EMS organizations. While communities may overwhelmingly recognize the need for fire departments, they’re not as certain about EMS organizations.In smaller areas, two 24/7 hospitals aren’t necessary, Hughes says. There needs to be less competition and more coordination. “Most traumas can be handled locally,” Hughes says. “A good trauma system reduces the number of unnecessary transfers to cities or other states, saves money and saves lives.”

Rescuing emergency care

“Providing new community-based services can be more challenging for rural agencies,” Wingrove says. “In a town of 3,000, if you have a for-profit ambulance service with paid staff, you’re in a small town without much volume,” he says. “As the owner of ambulance service, you’re rightfully concerned about to your ability to generate revenue.”

Some healthcare companies and ambulance services are looking to a newer model of emergency care, called community paramedicine. This shift could both reduce emergency visits and provide stable employment for paramedics, lessening reliance on volunteers.

The basic idea is that community paramedics furnish a broader range of healthcare services than paramedics otherwise would. They might provide home healthcare services for homebound patients, or fill in for physicians in urgent but not emergency situations during their off hours. In one Minnesota county, paramedics also provide care at county jails, Wingrove says, and in another, they provide basic, vital care for nursing home patients who don’t have primary care physicians.

This model of healthcare also helps reduce unnecessary, expensive ER trips, which can clog the response system by taking up beds, resources and time. Community paramedics can conduct home visits for people who’ve been relying on 911 and the ER for lower-risk health issues. Paramedics are trained to determine when patients can’t be cared for at home.

“Headaches, belly pain and anxiety are the vast majority of ER visits,” says Dr. James Bush, medical director at the Wyoming Department of Health. “We’d rather pay paramedics to keep patients in the home.”

Wyoming also works with telehealth services, which use videoconferencing and mobile apps to diagnose, monitor, treat and manage patients remotely. These telehealth services have enabled thousands of “virtual visits” over the past 10 years, Bush says. Patients with urgent conditions, such as an ear infection, can use encrypted Internet connections (as required by federal health privacy law) to contact their physicians, reducing strain on emergency care facilities.

Samaritans saving lives

In rural America, bystanders are also being trained to help at the scene of an accident, such as a road collision or farm equipment injury, according to Stop the Bleed, an American College of Surgeons public education program. The program’s goal is twofold: to place bleeding-control kits in every public venue and to train passersby to stop emergency bleeding until professional help arrives.

“We’re training laypeople to stabilize and stop hemorrhage,” Hughes says, “and that’s going to make a huge difference in whether people are going to survive or not.”

Telehealth services and bystander-assistance measures can help fill in treatment gaps. But Gienapp says we still need to improve rural emergency care if we want to see the injury fatality rate come down. “Emergency care is in trouble,” Gienapp says. “Rural, critical-access hospitals are on the edge of being able to stay afloat, and emergency medical services agencies are understaffed.”

Addressing the problem, Gienapp says, will take “creative people with different solutions” acknowledging what’s going on in rural America. “If we keep sticking our heads in the sand and saying that it’s not a problem,” he says, “we’ll soon find out how big a problem it really is.”

Lora is a Seattle-based writer who focuses on health, personal finance, career, education and travel.

Read this next

For people with irritable bowel syndrome, it’s common to hear that symptoms such as cramping, alternating diarrhea and constipation, and bloating are “all in their head.” In the case of IBS, there’s actually some truth to this.

It’s not that their symptoms don’t exist. IBS is a very real disorder, and managing its physical toll often becomes an all-consuming effort. The litany of concerns that accompany so many activities — always scouting the closest bathroom, making sure you can reach it in time, farting in public — keeps many people with IBS from having a social life.

Yet according to some experts, IBS is not solely about what’s going on in the digestive system; rather, the brain exacerbates the condition. “IBS is a disorder of brain-gut dysregulation,” explains GI psychologist Sarah Kinsinger, who is also co-chair of the psychogastroenterology section of the Rome Foundation. Accordingly, addressing the “brain” side of IBS through cognitive behavioral therapy with a trained psychologist may help decrease both the anxiety that’s often associated with the disorder and its physical symptoms.

“CBT really should be the first-line treatment for people with IBS. It’s the treatment with by far the most empirical support, and when done well, it can be curative,” says Melissa Hunt, associate director of clinical training in the psychology department at the University of Pennsylvania.

In a series of trialspublished last year, researchers in the UK compared the standard treatment for IBS (typically diet and lifestyle modifications and/or medication) with eight sessions of CBT delivered over the phone or online. Before and after the trials, participants answered questionnaires designed to measure their anxiety, depression and ability to cope with their illness. Two years after the trials, 71 percent of the phone-CBT group and 63 percent of the online-CBT group reported clinically significant changes in their IBS symptoms. Meanwhile, less than half of the standard-treatment group reported such an improvement. Those who did CBT also exhibited lower levels of anxiety and depression and higher coping ability than other participants.

In an earlier meta-analysis (a study of studies), published in 2018 in the Journal of Gastrointestinal and Liver Diseases, a different team of researchers also found that CBT appeared to reduce both psychosocial distress and the severity of IBS symptoms, with a greater effect on the physical symptoms than on the mental ones.

Explainers

The brain-gut connection

How this happens is not completely clear at this point, but it’s believed to have something to do with how the gut and brain communicate.

“IBS is thought to be a disorder of centralized pain processing,” Hunt explains. “There is miscommunication between the pain centers in the brain and the nerves in the gut. In people with IBS, pain signaling gets inappropriately amplified.” Discomfort that wouldn’t even register in the majority of people feels like being stabbed in the gut to a person with IBS. “The best way to address that is to find ways to help reduce pain signaling, and that’s with a psychologist,” Hunt says.

CBT for IBS entails learning relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, which help reduce the “volume” of the pain signals by activating the parasympathetic nervous system, i.e., the body’s “rest and digest” response. “This can also lead to increased blood flow and oxygen to the digestive system, which helps the GI tract to function in a more rhythmic way,” says Kinsinger, who is also an associate professor at Chicago’s Loyola University Medical Center.

CBT also involves thought restructuring. IBS can cause a cycle of worry: Worrying about symptoms leads to being hyperfocused on the slightest hint of any symptom, which increases anxiety, which aggravates symptoms. People with IBS also often catastrophize, meaning they assume the worst will happen (“If I have an accident at work, I’ll get fired and never get another job”), develop social anxiety and become withdrawn. CBT addresses these issues by shifting attention away from IBS symptoms and using exposure therapy to help people gradually engage in more activities outside their homes.

Additionally, using CBT, people with IBS learn to identify and change dysfunctional ways of thinking. For example, consider someone with school-aged children who asks their spouse to attend all school functions because they’re afraid of farting in a room with other parents, which would inevitably cause humiliation and might even make people think they’re disgusting A therapist might ask them how often they notice bodily noises from other people to help them realize that we’re a lot more cognizant of our own bodily functions than other people are. “In other words, we identify the catastrophic beliefs and then search for evidence supporting them or not,” Hunt says.

CBT is a skills-based, goal-oriented approach to treating mental disorders that emerged in the mid-20th century. All CBT programs share the same underlying goal of helping patients identify and modify negative or unhelpful thought patterns and behaviors. “It teaches patients techniques that they can then implement on their own.” says Kinsinger. “It can be done pretty efficiently, depending how motivated and receptive one is to learning these skills.” But over time, customized versions of CBT have been developed for specific conditions including insomnia, schizophrenia and IBS. Different versions of CBT use different techniques, such as role-playing, exposure therapy and relaxation exercises, and vary in length. On average, CBT for IBS lasts between 4 and 10 sessions in total.

Jeffrey Lackner, professor and chief of the division of behavioral medicine at the University at Buffalo, SUNY, says their program is structured like a course: “You learn a specific skill to manage your GI symptoms, process information differently or respond to stress in a less extreme way. Then you practice that skill in session before using it in the real world.” Often therapists also give patients homework to fine-tune the skills they learn. They come out of CBT with a toolbox of techniques to manage the day-to-day burden of IBS.

Some people with IBS do CBT on their own, using self-help books, online materials or apps without ever seeing a therapist. “Not many psychologists are trained to treat GI disorders specifically, so physicians don’t often have anyone to refer patients to,” Kinsinger says. The Rome Foundation trains psychologists and maintains a directory of gastrointestinal psychologists, but if someone can’t find a provider in their area, Hunt and Kinsinger recommend looking for a psychologist who’s trained in CBT and has experience treating chronic pain, panic disorders or anxiety.

Reducing sensations vs. reducing sensitivity

Not everyone is fully on board with CBT for IBS. One 2018 review study found “insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases” including IBS. A different 2018 review concluded that although psychological treatments for IBS appear to help in clinical trials, it’s unclear if they work in other settings and which treatments — such as CBT, mindfulness-based stress reduction and guided affective imagery — are most effective.

IBS is a complex problem, and some doctors prefer to integrate CBT with other treatments. But “by the time we see them,” Lackner says, “many of our patients have found that the medical treatments have not provided adequate symptom relief.”

Some IBS patients also find thetraditional approaches too hard to stick with. The most commonly prescribed treatment is a “low-FODMAP” diet, which requires giving up all dairy and legumes, plus many grains, fruits and vegetables. “Some trials show that even if the diet reduces or eliminates GI symptoms, it doesn’t improve quality of life because it’s crazy restrictive,” Lackner points out.

“With IBS, the nerve endings in the gut have become hypersensitized, and the brain magnifies those signals in the gut,” Hunt says. “The low-FODMAP diet tries to reduce the sensations, whereas CBT reduces the hypersensitivity. When you turn down the volume on the sensations, then you can eat whatever you want.”

Whether CBT helps with this brain-gut dysregulation, addresses distorted thinking and anxiety, or increases confidence in a person’s ability to manage gastrointestinal symptoms — or all of the above — it’s helped people with IBS resume parts of their life they’d put on hold.

Brittany Risher is a writer, editor and digital strategist specializing in health and lifestyle content. She's written for publications including Men's Health, Women's Health, Self and Yoga Journal.

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